Attachment integrated claims system and operating method therefor

ABSTRACT

An attachment integrated claims (AIC) system is formed by a combination of first, second and third storage media. The first storage medium stores computer readable instructions for permitting a first computer system to receive textual data as field data, where each of the field data is displayed on a predetermined portion of a first screen of the first computer system, to assemble the field data and a corresponding digitized image into a first file having an integrated file format and to transmit the first file to a second computer system via a communications channel. The second storage medium stores computer readable instructions permitting the second computer system to receive the first file via the communications channel, to display the corresponding digitized attachment on a second screen of the second computer system, and to transfer the field data to a third computer operatively connected to the second computer. In addition, the third storage medium stores computer readable instructions permitting the third computer system to receive the field data from the second computer, to display the field data on a third screen and to generate a second file including portions of the field data extracted from the first file. In other words, the AIC system permits transmission of a customizable claim form and integrated attachment to an insurance carrier via a non-clearinghouse communications channel. An AIC system including several computers connected via a communications channel, an electronic file, and an operating method therefor are also described. In an exemplary case, the first file follows a predetermined graphic image interchange file format and the field data is incorporated into comment blocks associated with the predetermined graphic image interchange file format.

This is a continuation of application Ser. No. 08/824,010, whichapplication was filed on Mar. 25, 1997, now U.S. Pat. No. 6,003,007 andwhich application is pending.

BACKGROUND OF THE INVENTION

The present invention relates generally to an attachment integratedclaims (AIC) system for preparing and processing forms with integratedattachments. More specifically, the present invention relates to an AICsystem for preparing and processing digital insurance claims includingPrior Approval Claim (PAC) Applications containing both a text form andan integrated digitized attachment. A method of operating a totallydigital AIC system is also disclosed.

High administrative costs for filing and processing health insuranceclaims have been the bane of the health insurance industry from itsinception. Over the years, many attempts have been made to develop afaster and more cost effective claims processing system. Three stages inthis development effort are described in the following correspondinglynumbered paragraphs.

(1) The original system involved hard copy paper claims only, withtransmission and all processing done manually. Originally, an insuranceclaim was filed by the patient or the health care provider filling out apaper form. The completed paper form was then mailed to the insurancecompany. At the insurance company, the paper claim form went through aseries of administrative steps, all the time remaining as a hard copypaper object. When a decision was made, the decision was written up andarchived with the claim form; a hard copy was also sent to the patientand/or provider along with the payment.

(2) The first significant advancement resulted from the introduction ofthe mainframe computer. This allowed for electronic processing within agiven insurance company, i.e., once the claim was on the computer insidethe company, the paper form could be dispensed with. Computerization isa highly effective way of reducing administrative overhead in claimsprocessing.

Thus, mainframe computers were purchased and installed internally at theinsurance companies. Since these computers were intended for internaluse only, each company thought only of its own needs and had its claimsmanagement software customized. While the claims management software fora number of insurance companies would be written in the same high-levelprogramming language, e.g., COBOL, the similarity between softwareprograms often ended there. There were many virtues to these earlysystems, primarily with respect to decreased administrative costs, but amajor drawback was that the data for each "paper" claim had to beentered into the computer to form an electronic claim. This necessitatedthe manual transcription of exactly the same information that had beenhandwritten into the original paper claim before it was sent to theinsurance company.

(3) The next advancement was the electronic filing of claim forms. Thiswas made possible by the introduction of the personal computer and modeminto the provider's office. The main purpose of this stage was toeliminate the manual re-entry of information into the insurance companymainframe.

The basic idea was to have the providers fill out an electronic claimform, instead of a paper claim form. This electronic form, which wouldbe stored in the memory of their PCs, would then be transmitted, as acomputer file, to the insurance company. It could then be integrateddirectly into the electronic claims processing system without the manualre-entry of data. Thus, the technology existed to produce a system thatcomputerized the overall filing and processing of the insurance claimfrom the point of entry, the provider's office, to the final report ofthe claims adjuster.

Although the idea was straightforward, implementation was not. Two basicproblems had to be overcome in order to create a viable system. First,the information contained in the electronic claim form had to beintegrated into the claims processing software at the insurance company.Second, a majority of providers have to be able to interface with amajority of insurance companies, i.e., insurance company mainframecomputers. However, because of the way computers had entered theinsurance industry originally (stage #2), there was no industry-widestandard, i.e., the legacy mainframe computers of the differentinsurance companies were incompatible. This was true both with respectto the type of software used and with respect to the information thateach company required on its claim form.

One attempt to deal with these problems was the creation, by aconsortium of insurance companies, of the National ElectronicInformation Corporation (NEIC). NEIC's basic function is that of aclearinghouse. It interfaces between the insurance companies and theservice providers. It also establishes rigid standards that must be metin order to transmit an electronic claim form to an insurance company.In practice, the service provider sends an electronic claim to a vendor,who performs a service such as screening of the form. The vendor thentransmits the form to NEIC, which then re-transmits it to the patient'sinsurance company. Since it is a computer file, the information in theelectronic claim form can then be entered directly into the company'smainframe claims processing system, without the manual re-entry of data,and then processed.

Thus, a coherent system was created that allows for the electronicfiling, transmission, and processing of insurance claims. This system isemployed by thousands of providers and hundreds of insurance companies.

NEIC was designed to act as a clearinghouse for claims that are 100%text and that conform to very restrictive formats. For claims that meetthese conditions it functions well, resulting in substantial savings onadministrative costs for the insurance companies. It has been estimatedthat going to this third stage system results in savings of as much as60% in claims processing costs.

But there are many claims that do not meet these conditions. These wouldinclude claims that require additional text information that doesn't fitinto the prescribed format and/or claims that require non-textinformation. In general, these are called "claims with attachments.""Attachments" are any additional information that must be sent with the"standard text claim form." This could include: pictures, graphs,additional text not allowed on the standard claim form, soundrecordings, etc.

An example of such a claim would be the PAC (Prior Approval Claim),which may be alternately denoted as a "Pretreatment Claim". These areclaims that are sent to the insurance carrier before a procedure isperformed. For example, pretreatment claims are often required by dentalinsurance companies on any procedure over a specified amount, e.g.,$200. The aspect of this type of claim which renders it incompatiblewith the present electronic claim processing system is that theinsurance companies require that additional medical evidence beincluded, i.e., attached to, the text part of the claim form. In anexemplary case, the additional medical evidence is an x-ray.

The goal of the insurance company is to review the claim, i.e., both thetext form and attachment, and to do so in a cost effective manner. Thenatural next stage in the development of claims processing systems is toattempt to computerized this process.

Scanners are now available that can digitize a dental x-ray, i.e.,convert it into a computer file that can be viewed on a monitor. Buttransforming the medical evidence into digital form is not enough tofacilitate electronic processing of claims with attachments. One mustalso take into consideration the existing claims processinginfrastructure, i.e., the legacy infrastructure.

The difficulty with trying to include a digitized x-ray for processingwith an electronic claim form, within the current infrastructure, ismultifaceted. First, NEIC does not at the present time allow this typeof information to be transmitted through NEIC to the insurancecompanies. Second, with the current system, the claims adjusters accessclaims information through terminals connected to mainframes. But thereis the inherent problem of displaying images on mainframe computers.This is especially true of mainframe computers running software writtenin business programming languages such as COBOL. It might be thoughtthat a solution to this problem would be to replace the terminal with aPC. Although many personal computers provide the graphics support neededto display the digitized x-ray, there are significant problems ininterfacing a PC with a mainframe computer. For example, in order tointerface with the mainframe computer, PCs often run terminal emulationsoftware which permits the PC to act like a dedicated, dumb terminalattached to the mainframe computer. Terminal emulation software isnotoriously lacking in graphics capability. And finally, getting adigitized x-ray from one provider to one insurance company is not allthat is needed. Rather, what is really needed is an industry-wide systemwhereby a provider can interact with any insurance company. This resultsin a massive interfacing problem since there are multitudes of insurancecompanies using different legacy hardware systems and company uniquesoftware.

Each time a way has been found to more fully utilize computers in claimsprocessing systems, the administrative costs associated with claimsprocessing have gone down. However, in the area of "claims withattachments," no coherent industry-wide system exists that allows forthe integrated filing, transmitting and processing of these claimselectronically, i.e., via computers. Thus, when attachments arerequired, providers are forced to submit hard copy claim applications,while insurance companies labor under an administrative system that is ahybrid between a manual and an electronic system, i.e., a hybrid betweenstage #1 and stage #2. This hybrid system, which is described in greaterdetail below, is labor intensive, prone to problems, and slow. Forproviders, insurance companies, and patients, this is a time-consuming,costly and irritating process.

In short, there is at least one type of insurance claim that has not,until now, been able to avail itself of the third stage ofcomputerization, as described above. In fact, there are evendifficulties with the second stage. This group includes any claim whose"standard text form" must be accompanied by additional information thatdoes not fit into this standard format, e.g., x-rays, EKGs, additionaltext information such as Operating Room Reports, etc. In general, theseare referred to as "attachments." One primary example of this would bePrior Approvals for dental procedures. Prior Approval Claim (PAC)applications are those claims that are submitted for the purpose ofreceiving a predetermination of benefits from the insurance company fora procedure that hasn't as yet been performed.

In the area of Prior Approval Claims, the goals of the insurancecompanies are to validate the necessity of the procedure and todetermine whether the patient's insurance policy obligates the insurancecompany to pay for such a procedure. This requires that the insurancecompany itself review the medical evidence. For an insurance company'sin-house dentist, for example, to make this appraisal, the dentist isrequired to review both the "text form" and the accompanying x-ray ofthe patient. However, the presence of a film x-ray means that electronicclaims methods cannot be implemented. The savings associated withelectronic claim processing is not available with respect to PriorApproval Claim forms.

Nationwide, there are approximately 200,000 dental PACs filed per week.Roughly, for every PAC application there will be eventually a FinalPayment Claim (FPC) submitted when the medical procedure is completed.It is estimated that the overall administrative cost is $25 per PAC formand $10 for the Final Payment Claim. It is also estimated that if acoherent electronic system could be implemented, it would reduce theseadministrative costs to $15 per PAC and $5 per Final Payment Claim. Thesavings could amount to as much as $3,000,000 per week collectively forthe health care industry for dental PACs and FPCs alone.

An example of a hybrid system of claim processing currently in use willnow be described with reference to FIGS. 1, 2A and 2B.

Referring first to FIG. 1, the U.S. Postal Service, denoted as 100,connects the service provider's office 200 with the insurance company300. It will be appreciated that, since PAC form handling is entirelymanual at location 200, the service provider's office is depicted aslacking computer equipment. In contrast, the insurance company typicallyhas at least one mainframe computer 350 to which terminals 351, 352 onthe respective reviewing dentist's and claims adjuster's desks areconnected. It should also be noted that the mail room 320 is chargedwith a variety of tasks associated with the incoming and outgoingcorrespondence, as discussed in greater detail below.

As will be appreciated from FIG. 1, a paper PAC form is filled out bythe patient and/or the provider and, along with the substantiatingx-ray, is mailed to the patient's insurance company. Upon entering themail room of the insurance company, the PAC form is assigned a documentidentification number (DIN) and the data from the PAC form is thenentered into the company's mainframe computer. This same DIN is affixedto the x-ray. The x-ray is then manually delivered to the reviewingdentist.

By using the DIN on the x-ray, the reviewing dentist downloads, from themainframe computer, the textual part of the patient's PAC application.The dentist makes a decision, records it in the memory of the mainframecomputer, and has a hard copy of the Predetermination form posted backto the provider. Once the procedure has been completed, the provider'soffice completes the Predetermination form, or fills out a separateFinal Payment Claim (FPC) form. This is then posted to the insurancecompany. A chronological, detailed, step-by-step description of thehybrid system will now be provided with reference to FIGS. 1, 2A and 2B.

During step S1, the dentist decides that a costly procedure is necessaryfor a patient whose insurance carrier requires prior approval for suchtreatment. During step S2, the dentist provides the patient with hisdiagnosis and gives the patient an estimate for performing therecommended procedure. The dentist then asks the patient to contact hisinsurance carrier, or plan administrator at work, to obtain thenecessary PAC form. During step S3, the patient completes that portionof the PAC form that pertains to him, signs the form, and sends it tohis provider.

After the PAC form arrives at the provider's office at step S4, one ofthe office personnel retrieves the patient's file and the PAC form atstep S5, extracts the patient's x-ray, either the original, a copy ofthe original, or a second, previously taken x-ray, during step S6, andthe PAC form is filled out entirely by hand, i.e., the information aboutthe provider has to be entered every time a new PAC form is received,during step S7. Copies of the completed form are made and are placed inthe patient's file during step S8. The envelope containing the PAC formis addressed to the appropriate insurance company at step S9. The formand the x-rays are placed in the envelope during step S10. An entry ismade in both the patient's computer file (if the provider's office isequipped with one) and his hard copy file indicating that the PAC formhas been sent during step S11 and, finally, during step S12, theenvelope is mailed. See task T1 in FIG. 1.

The envelope meanders through the U.S. Postal Service 100 for severaldays at step S13 until the envelope finally arrives at the mail room 320of the insurance company 300 at step S14. In the mail room, the envelopeis opened (step S15), the data from the PAC form is entered into theinsurance company's mainframe computer 350 and is given a DocumentIdentification Number (DIN) that identifies the patient and the currentclaim application (step S16). See task T2 in FIG. 1. During step S17,the x-ray is labeled with the same DIN. It will be appreciated that theDIN on the x-ray and in the document now on the mainframe computer mustbe identical. It will also be appreciated that for some insurancecompanies, this manual processing is contracted to an outside agency,which would require several more steps, which steps will not bedescribed further.

During step S18, the x-ray is manually forwarded to the reviewingdentist's area. See task T3 in FIG. 1. During step S19, the PAC form istransferred to a directory and waits to be read by a reviewing dentist.

During step S20, a group of x-rays arrives from the mail room at thereviewing dentist's area. A film x-ray is pulled out of the waiting pileby the dentist during step S21 and the reviewing dentist then accessesthe "PAC form" directory during step S22 by, for example, reading theDIN from the x-ray and typing the DIN into the computer. The electronicPAC form corresponding to this x-ray is located in memory and downloadedto the reviewing dentist's monitor during step S23.

The procedure requested is read off the terminal monitor and the filmx-ray is reviewed during step S24 and a determination is made duringstep S25. It will be appreciated that a determination refers to eitheran approval or a denial of the request. Assuming that the procedure isapproved, a statement (or explanation) of benefits (EOB) is alsogenerated. For the purposes of this discussion, it will be assumed thatthe procedure is approved; a denial would necessitate a parallel butalternative set of processing steps, which steps will not be furtherdescribed. During step S26, the insurance company's Predeterminationform is filled out either electronically or by hand. For an electronicPredetermination form, the form is saved to the memory of the insurancecompany's mainframe computer during step S27. The x-ray is returned tothe mail room during step S28. See task T4 in FIG. 1.

Following approval, a paper copy of the Predetermination form is madeduring step S29. See task T5 in FIG. 1. An envelope is then addressed tothe referring dentist and the Predetermination form is placed in theenvelope during step S30. During step S31, the corresponding x-ray ismatched with the Predetermination form and, during step S32, thecorresponding x-rays are placed in the envelope. The envelope then goesback into the U.S. Postal System 100 during step S33. See task T6 inFIG. 1.

Some days later, the envelope finally arrives at the dentist's office200 and is opened during step S34. The results are noted in both thepatient's paper file and computer file during step S35, the x-rays arereturned to the patient's paper file at step S36, and the patient isnotified of the approval and a date is set for performing the approvedtreatment during step S37.

The treatment is completed during step S38 and the Final Payment Claim(FPC) form is filled out during step S39. It will be appreciated thatthe Final Payment Claim form, for many insurance companies, is merely asubsection of the Predetermination form generated in step S29 (See thepaper denoted P* in FIG. 1.); alternatively, the Final Payment Claimform could be yet another form supplied by the insurance company.

The Final Payment Claim form is then sent back to the insurance companywith a copy of the signed Predetermination form during step S40. Seetask T7 in FIG. 1. The Final Payment Claim form enters the mail room asa paper form and the final processing begins during step S41. It will beappreciated that the processing of the Final Claim Form typicallyrequires making several entries in the information stored on themainframe computer 350 and may require the preparation of one or moreforms needed to authorize payment of the final claim. However, since anattachment is not normally associated with the Final Claim Form,additional discussion regarding disposition of the Final Claim Formwithin the insurance company will not be provided.

Thus, the hybrid system under discussion is one that starts in theprovider's office when a patient is told that a PAC form is needed andcontinues until the procedure has been completed and a Final PaymentClaim form has been submitted to the insurance company for payment. Itwill be appreciated that a myriad of problems and inefficiencies arisedue to claim processing in accordance with the hybrid system. Theprincipal problems are as follows:

1. All information needed to complete the PAC form has to be entered byhand. Moreover, all of the information on the PAC form is also manuallytranscribed in order to transfer the information from paper to theinsurance company's mainframe computer. Both of these manual data entryprocess steps are time consuming, very costly, and prone to human error;

2. The x-ray film and the text form are put together and then separatedseveral times during the overall claim processing;

3. The hybrid system requires that a hard copy of the x-ray be sent tothe insurance company. Generally, this x-ray is returned to theprovider. Moreover, the requirement that the dentist provide the x-raytypically means that a duplicate x-ray has to be made by the dentist,which increases the dentist's cost for the service. Oftentimes, theduplicate x-ray is of poor quality and cannot be read;

4. Because prior approval claim forms cannot be processedelectronically, and because PAC forms make up half of all the claimsthat approximately 20,000 oral surgeons, periodontists, andorthodontists make each year, these 20,000 providers have no compellingreason to initiate electronic claims or Final Payment Claims;

5. The document identification number is affixed to the x-ray and theelectronic text in two different processes, one physical and the otherelectronic. This leads to errors;

6. After the procedure has been completed, almost identical informationmay again have to be entered by hand in order to prepare the FinalPayment Claim form;

7. While direct digital x-ray equipment is available, it is difficult tointegrate a digital x-ray into the current hybrid claims processingsystem, i.e., these computerized images would first have to betransferred to film, which would, of course, negate the major advantagefor using direct digital x-rays;

8. Some insurance companies would like to require that x-rays accompanyall dental claims; they are prevented from doing so because of the highadministrative overhead associated with handling hardcopy claims;

9. The patient has to obtain the PAC form from the insurance company orhis employer. In either case, this causes the patient time, is anirritant, and imposes unnecessary delays on the delivery of medical careto the insured;

10. With the hybrid system, no prescreening of the PAC form for errorsis performed before the PAC form goes to the insurance company; and

11. Provider information, i.e., the dentist's information, often has tobe entered separately on each new PAC form that is submitted.

In summary, the current method for handling PAC applications is a hybridsystem somewhere between a Stage 1, a totally paper-based manualprocessing system, and a Stage 2 internally computerized insurancecompany processing system. It is part electronic and part hard copy.Also, each form must be handled twice, once as a hard copy and once asan electronic copy. This is the source of a great many of the abovedescribed problems. Moreover, the current hybrid method is costly. Theprocess starting at the provider's office, continuing through theinsurance company and finally to the return of the Predetermination formto the provider has been estimated to cost $25. Furthermore, the wholeprocess is filled with potential for error, frustration, wasted time andmoney.

The workflow for the filing and processing of a PAC form was describedabove with respect to the dental health insurance which was used, by wayof example, to illustrate the circuitous process involved when a hardcopy attachment is present. Other types of claims, or attachments, ordifferent insurance companies might require slightly different steps.For example, instead of returning an attachment, as describe above, theattachment might need to be microfilmed and archived, or some of theinformation contained in the attachment itself might need to be enteredinto the mainframe. Regardless of these differences, there aresimilarities in the problems that arise in processing such claims.

The present invention was motivated by the desire to overcome theproblems associated with the above-described hybrid system forprocessing "forms with attachments." The intent was to create a coherentsystem that allows for the electronic filing, transmission, andprocessing of these forms, e.g., claims. That is, a system that wouldcreate a Stage #3 level of computerization for "forms with attachments."More specifically, the present invention was motivated by the desire toeliminate, to the maximum extent possible, all processing stepsdescribed above which are in any way connected with the presence of ahard copy attachment.

SUMMARY OF THE INVENTION

One purpose of the present invention is to create a coherent system thatallows for the electronic filing, transmission, and processing of"insurance claims with attachments," and to thereby overcome the manydeficiencies of the hybrid system claims processing methodologydescribed above.

Thus, one object according to the present invention is to provide a PACform processing system which minimizes the necessity of manual dataentry. According to one aspect of the present invention, only about 40%of the information needed to complete the PAC form has to be entered byhand. According to another aspect of the present invention, the amountof information that has to be manually re-entered by an operator isessentially zero.

Another object according to the present invention is to provide a PACapplication processing system which eliminates handling errors resultingin a mismatch between, for example, a PAC form and an associated patientx-ray. According to another aspect of the invention, mismatch errors arevirtually eliminated since the electronic x-ray and the associated textare never separated; field data included in, for example, the PAC formis copied and transferred between the server and the mainframe computersystems inside the insurance company. According to yet another aspect ofthe invention, mismatch errors are virtually eliminated since no hardcopy of the x-ray is ever sent to the insurance carrier.

Still another object according to the present invention is to provide aPAC application processing system which increases the number of serviceproviders employing electronic claims systems to thereby reduce theoverall claims processing costs. Since a PAC form can now be handledelectronically in accordance with the present invention, electronicfinal payment claims become viable for approximately 20,000 additionaldentists.

A still further object according to the present invention is to providea PAC application processing system in which Document IdentificationNumbers, or some other method of uniquely specifying the PAC, aresimultaneously associated with both the text and the x-ray by a singlecomputer entry.

Yet another object according to the present invention is to provide aPAC application processing system which operates at lower cost. Costefficiencies are readily achieved according to the present invention byeliminating the need to send a physical x-ray with the claim.

Another object according to the present invention is to provide a costeffective claim processing system wherein little or no information oneither the PAC form or the Predetermination form has to be manuallyre-entered.

Still another object according to the present invention is to provide asystem for packaging textual data with an associated digitized x-ray fortransmission to an insurance company. It will be appreciated that directdigital images are easy to integrate into the system because such imagesare already in the form of a computer file.

Another object according to the present invention is to provide atotally digital PAC application processing system which can accommodateboth text and digitized x-rays at low cost, thereby allowing insurancecompanies to require x-rays with all claims because such requirementswill not significantly increase the processing cost associated withnon-x-ray documented claims.

An additional object according to the present invention is to provide atotally digital PAC application processing system in which acustomizable claim form, i.e., the PAC form, which addresses the needsof all insurance carriers is stored in the memory of the computer inevery service provider's office. This, in combination with anon-clearinghouse communications channel and having AIC system softwareat all of the insurance carriers, then eliminates the need for imposingindustry-wide standards, such as ANSI ASC X12, for claim-relatedelectronic transactions. The present invention allows each individualinsurance company to get the information that it requires and to getthat information in what ever format that insurance company prefers.Moreover, the ability to transmit the customizable claim form andintegrated attachment to an insurance carrier via a non-clearing housecommunications channel advantageously permits the transmission of othertypes of claims, including worker's compensation claims, to theinsurance carrier. In addition, it will eliminate the irritant of thepatient or provider having to obtain a PAC form from a particularinsurance company.

Another object according to the present invention is to provide atotally digital PAC application processing system in which prescreeningof information entered into a PAC form, which is stored in the memory ofthe computer in the service provider's office, is easily performed.

Yet another object according to the present invention is to provide atotally digital PAC application processing system in which providerinformation is automatically entered into each PAC form.

It will be appreciated that none of the above-identified objects needactually be present in invention defined by the appended claims. Inother words, only certain, and not all, objects of the invention havebeen specifically described above. Numerous other objects advantageouslymay be provided by the invention, as defined in the appended claims,without departing from the spirit and scope of the invention.

These and other objects, features and advantages according to thepresent invention are provided by a combination including (1) a firststorage medium storing computer readable instructions for permitting afirst computer system to receive textual data as field data, to assemblethe field data and a corresponding digitized attachment into a firstfile and to transmit the first file to a second computer system via acommunications channel, (2) a second storage medium storing computerreadable instructions for permitting the second computer system toreceive the first file via the communications channel, to display thecorresponding digitized attachment on a second screen of the secondcomputer system, and to transfer the field data to a third computeroperatively connected to the second computer, and (3) a third storagemedium storing computer readable instructions for permitting the thirdcomputer system to receive the field data from the second computer, todisplay the field data on a third screen of the third computer systemand to generate a second file including portions of the field dataextracted from the first file.

According to one aspect of the present invention, the first file followsa predetermined graphic image interchange file format providing commentblocks for text, so as to permit the field data to be incorporated intothe comment blocks associated with the predetermined graphic imageinterchange file format.

These and other objects, features and advantages according to thepresent invention are provided by a method for operating a computersystem including first, second and third computers, each of the first,second and third computers including a memory, an input device, and adisplay, respectively, the first and the second computers beingconnected to one another by modems and a common communication line, andthe first computer including a digitizing device. The method includessteps for:

(a) retrieving a first form from storage in the first computer's memoryand displaying the first form on the first computer's display;

(b) writing first field data to the first form using the firstcomputer's input device;

(c) digitizing a patient's x-ray to thereby generate a digitized x-ray;

(d) combining the digitized x-ray and the first form so as to generatean attachment integrated file by inserting the first field data into acomment block within the digitized x-ray so as to generate an attachmentintegrated file;

(e) transmitting the attachment integrated file to the second computer;

(f) transmitting the first field data from the second computer to thethird computer;

(g) generating a second form upon receipt of the attachment integratedfile, the first and second forms containing at least a portion of thefirst field data;

(h) displaying the first form, the second form and an imagecorresponding to the digitized x-ray on respective displays of the thirdcomputer and the second computer;

(i) writing second field data to the second form using the secondcomputer's input device;

(j) transmitting the first and second field data corresponding to secondform back to the first computer.

These and other objects, features and advantages of the invention aredisclosed in or will be apparent from the following description ofpreferred embodiments.

BRIEF DESCRIPTION OF THE DRAWINGS

The preferred embodiments are described with reference to the drawingsin which like elements are denoted by like or similar numbers and inwhich:

FIG. 1 is a combination high level block diagram and flow diagram whichis useful in understanding the operation and attendant problems of thecurrent hybrid system for Prior Approval Claim form processing;

FIGS. 2A and 2B collectively form a flow chart which illustrates ingreater detail the steps needed to implement the hybrid system of FIG.1;

FIG. 3 is a combination high level block diagram and flow diagram whichis useful in understanding the operation and system of Prior ApprovalClaim form processing according to a preferred embodiment of the presentinvention;

FIG. 4 is a detailed flow chart of the operational steps needed tooperate the system illustrated in FIG. 3;

FIGS. 5A and 5B illustrate alternative embodiments of the attachmentintegrated claim application according to two of the preferredembodiments of the present invention; and

FIGS. 6A and 6B illustrate clearinghouse and non-clearinghouse networks,respectively, connecting service providers and insurance companies.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

The present invention is a system and corresponding method implementedby software loaded onto the system for processing textual messages whichare integrated with one or more attachments. Heretofore, suchattachments could not be readily and/or usefully incorporated with thetextual message. Hereinafter, the term Attachment Integrated Claim (AIC)Application will be used to denote a claim application including a textportion and a digital attachment portion. An exemplary embodiment of thepresent invention combines a patient's digitized x-rays with anelectronic insurance claim form to create an electronic Prior ApprovalClaim (PAC) Application. Another preferred embodiment of the presentinvention is an industry-wide system for the electronic filing andprocessing of these PAC Applications.

It should be noted that the term "digital attachment" as usedhereinafter is not limited to a digitized image or x-ray. The term"digital attachment" is understood to embrace x-rays, CTs, MRIs, EKG orEEG recordings, i.e., strip charts, digitized video signals such asMoving Picture Experts Group (MPEG) compressed video signals,transcriptions of Operating Room Notes, estimates for repairs to a houseor car, Explanation of Benefits (EOBs), additional ASCII text, and thelike. Moreover, all particulars regarding a specific "attachment," suchas medical specialty, acquiring modality, the patient's problem, etc.,are to be ignored, since such details have absolutely no bearing on thevarious embodiments of the present invention. The only requirementsregarding digital attachments are that the information must be somethingthat can be digitized, i.e., put into the form of a computer file, andthat once in this form, it can be "read, reviewed or interpreted" by theperson or organization receiving it.

The preferred embodiments according to the present invention will now bedescribed with reference to FIGS. 3 and 4. In particular, as shown inFIG. 3, the overall system according to the present invention includesthe computer components 200 located in the health care provider's officeand the computer components 300 located on the premises of the insurancecompany. Infrastructure 400, which advantageously may be an existingon-line service company, is preferably used in the exemplary embodimentof the present invention to facilitate communication between thecomponents 200 in the service provider's office and the components 300at the insurance company. Preferably, components 500, which are locatedat a value-added service company, permit services ordered by the serviceprovider, patient, or insurance company to be performed. It should benoted that the components 500 may duplicate a subset of the components300 found at the insurance company and, for that reason, description ofthe components 300 alone will be provided below.

It should also be mentioned that the description which follows describesthe invention as it is used in connection with dental insurance forms.However, the present invention is not limited to systems for theprocessing of dental insurance claims. Rather, the present inventionencompasses the preparation, transmission and processing of datapackages including a plurality of data fields wherein at least one ofthe data fields is a digital attachment, e.g., a digital image. Forexample, casualty insurance claims with supporting documentation, i.e.,pictures taken with a digital camera, are within the scope of thepresent invention.

As shown in FIG. 3, the components 200 include a personal computer 210including a screen 212, a keyboard 214 and a modem 216, connected to ascanner 220, a printer 230 and an archiving device 240, e.g., a largememory for storage of digital information. Device 240 advantageously maybe a writeable compact disc read only memory (CD-ROM), i.e., a so-calledwrite once-read many (WORM) device, a hard disk drive, a tape back updevice or a removable hard disk device. It should be recognized that thecomputer 210 advantageously can be a computer system including a centralprocessing unit, a graphic display processor, the graphic display device212, and several memories including both solid state memories and a harddisk drive. It should also be noted that the archive device 240 and oneof the memories associated with computer 210 may be the same memorydevice.

Components 300 located at the insurance company include the previouslydescribed mainframe or legacy computer 350 and associated terminals 351,352. In addition, a buffer computer 310, which may be a network server,includes a modem 316 and is connected to a printer 330 and a storagedevice 340. The printer 320 may provide copies of documents directly tothe mailroom 320. Preferably, the computer 310 is connected to personalcomputers or work station terminals 311, 312 via a local area network(LAN) 313. The buffer computer 310 and the mainframe computer 350 areelectronically connected to one another. The details of such aconnection are well known to one of ordinary skill in the art and willnot be described in greater detail.

Before presenting a detailed description of preferred embodimentsaccording to the present invention, a brief overview of the operatingmethod steps associated with formation, transmission and processing ofthe PAC Application will now be presented. In an exemplary andnon-limiting case, the essential steps of the operating method include afirst subroutine for completing and transmitting needed information to adesignated insurance company. This subroutine includes steps for:

(1) Retrieving an appropriate electronic PAC form from storage in thecomputer's memory and displaying the PAC form on the computer screen;

(2) Filling out of PAC form on the computer screen;

(3) Digitizing, e.g., scanning, the patient's x-ray;

(4) Combining the digitized x-ray and the electronic PAC form into thepatient's PAC application; and

(5) Transmitting the patient's PAC application to the designatedinsurance company.

After the PAC application is received by the insurance company, theinsurance company performs another subroutine, which includes steps for:

(6) Reviewing the PAC application;

(7) Generating an electronic Predetermination form when the applicationhas been reviewed; and

(8) Transmitting the electronic Predetermination form back to theinsured's Service Provider.

When the electronic Predetermination form from the insurance company isreceived by the service provider, an additional subroutine is performedby the service provider. This subroutine advantageously includes stepsfor:

(9) Reading the electronic Predetermination form;

(10) When the approved procedure has been performed, adding completiondata to the electronic Predetermination form; and

(11) Transmitting the annotated electronic Predetermination form back tothe Insurance Company.

When the annotated electronic Predetermination form is received from theservice provider, the insurance company performs a final subroutine,which includes steps for:

(12) Reviewing the annotated information; and

(13) Issuing the final payment to the service provider.

The method for operating the system according to a preferred embodimentof the present invention will now be described in detail.

The method starts at step S101 with the service provider's diagnosisthat a costly procedure is necessary. It is then determined that thepatient needs prior approval from his insurance company. During stepS102, the patient is provided with an explanation of the procedure and acost estimate for that procedure. The service provider and the patientthen prepare the needed PAC Application.

During step S103, a member of the service provider's office staffaccesses the Attachment Integrated Claims (AIC) software stored innon-volatile memory on the service provider's computer system 210, whichsoftware advantageously is Graphic User Interface (GUI) software.Preferably, this AIC software is written in C++, Visual Basic, or someother appropriate graphical programming language.

It will be appreciated that commercial software packages, such as LOTUSNOTES™, have been designed with the capability of addressingcombinations of text and graphics files. However, the purpose of thesepackages is to create an "environment" or "platform" in which specificapplications can be developed. In contrast, the preferred embodimentsaccording to the present invention are directed at providing integratedtext and graphics files within a coherent system and methodology foraddressing the specific needs of the work flow, preferably of aparticular industry. That is, it is a particular application. It ispossible, but not necessary, that the software needed to implement thepreferred embodiments of the present invention can be developed withinthe frame work of the environment created by something such as LOTUSNOTES™. Alternatively, the software needed to implement the preferredembodiments of the present invention can be developed using JAVA™applets.

Contained within the AIC software are PAC forms for insurance companiesusing the AIC system. When one of these is opened it acts as a templateupon which a new computer file will be based. This computer file willultimately contain the patient's PAC Application.

It will be appreciated that the PAC form when displayed on thecomputer's screen 212 contains boxes, such as those depicted in FIGS. 5Aand 5B, in which alpha-numeric characters can be entered so that, whenthe characters are entered in these boxes they are entered so as to filla "field," a delimited alpha-numeric character string. Being a "field,"the information denoted by the characters can be transferred to and usedin completing other fields in related documents. Also, the informationitself, or lack thereof, can be used as a logic control device, e.g.,used to remind the preparer that critical information has not beenentered.

In the exemplary case being discussed, the PAC forms of many insurancecompanies have been encoded and stored in memory on the serviceprovider's computer system 210. This can be advantageously done in thefollowing way. The PAC forms for all the insurance companies using theAIC System are gathered. Then a union of all the information requestedin these PAC forms is made. A field is created for each element ofinformation requested. For example, Field #1 contains the patient'sfirst name, Field #2 contains the patient's last name, and so on. Thisis done until the "information fields" of the PAC forms for all of theinsurance companies are included.

In order to increase the efficiency of the clerical staff at theprovider's office, it is desirable to give them basically the same formto fill out every time, i.e., information is always in the same place onthe form. To do this a template is created. What actually appears on thescreen of the preparer is always the same. What changes is that anygiven insurance company will desire only a particular subset of thetotal number of fields. So if insurance company A is chosen, then fields1,2,3,7,9, . . . have to be filled in, whereas, if insurance company Bis chosen, then fields 2,3,4,5,7,11, . . . have to be filled in. Thefields not needed are automatically signified in some way by the AICsoftware, e.g., if insurance company A does not need Field #4 then thatblock on the screen is gray and can't be typed into (i.e., is "writeprotected"). Thus a "customized claim form" is provided for everyinsurance company based on a single, universal compilation of fields. Asdescribed below, what allows this method to work is that there is AICsoftware at the insurance company that has been coordinated with the AICsoftware at the providers office.

The AIC Software GUI asks for the name of the insurance company, whichcan be typed in or selected from a directory. Once the insurance companyhas been identified, the fields needed to complete the insurancecompany's PAC form are displayed on the screen 212 of the serviceprovider's computer system 210. The AIC software advantageously canautomatically fill in all the parts of the form that are specific to theservice provider, e.g., name, address, Provider Identification Number(PIN), etc. It is estimated that this alone eliminates 20% of the workneeded to fill out the PAC form. An electronic signature couldadvantageously be added at this time for the service provider or couldbe added as part of the final review and approval before the completedPAC application is transmitted.

Needed patient information is then entered into the PAC form on thecomputer screen 212, preferably while the patient is still in theoffice, and a provider Document Identification Number (PDIN) can be usedto label the form, if so desired. This is now a computer file identifiedas referring to the patient. It should be noted that some form ofsignature can be provided in the appropriate field. As an example, aspecial electronic pad and pen can be used such that when the patientsigns on the pad his signature is affixed to the electronic PAC form.

During step S104, the patient's x-ray is digitized. In an exemplarycase, there is a scanner 220, i.e., digitizer, connected to the serviceprovider's computer system running the AIC software. The patient's x-rayis scanned and converted into a series of ordered numbers (i.e., a bitmap of the x-ray image) and stored. It should be noted that these storedseries of numbers can be reconstructed by the computer system to displaythe x-ray on a computer monitor, i.e., the bit map can be used toreconstruct a raster image of the x-ray for display.

It will be appreciated that the AIC software advantageously can bewritten to minimize the time needed to scan the x-ray. In an exemplarycase, the operator can specify the type of x-ray or x-rays that arebeing scanned. This is done so that blank areas are not being digitizedand added to the patient's file. It will be noted that this will alsosave on transmission time to the insurance company. Further, as will bereadily appreciated by those skilled in the art, the text and image datacomprising the file can be encoded and compressed in any manner wellknown in the art in order to minimize data storage and transmittingclaimed requirements.

It should also be mentioned that steps S103 and S104 need not beperformed in any particular order. In an exemplary case, the patient'sx-ray may be digitized before the PAC form is called up on the computerscreen 212 and completed.

During step S105, the PAC application is formed from the electronic PACform and the digitized patient's x-ray. It should be noted that thepresent invention is not limited to a particular format for the PACapplication. For example, the format of the PAC applicationadvantageously may consist of a text file and an associated digitizedimage file. It should be noted that in this case the text and imagefiles will be transmitted seriatim. For that reason, the text file(i.e., the PAC form) and the image file (i.e., the digitized x-ray) mustcross reference one another (i.e., be correlated) so that these filescan be continuously associated with one another after transmission tothe insurance company. If the attachment is simply additional ASCIItext, e.g., Operating Room Notes, then the only step necessary is totransfer the additional ASCII text into the integrated file format. Oncein the integrated file format, all processing is the same as if the filecontained an image attachment.

In an alternative exemplary case, the PAC application advantageously canbe prepared according to the Graphic Interchange Format© (GIF)specification, which specification is the intellectual property ofCompuServe Incorporated. In order to form the PAC application, thedigitized x-ray is converted to a GIF image file. It will be appreciatedthat the GIF image file advantageously can include one or more blocks oftextual data denoted by a comment extension, as described in Version 89aof the GRAPHICS INTERCHANGE FORMAT documentation published byCompuServe, Inc. It should be noted that since the textual informationcorresponding to the data needed to complete the PAC form is included inthe GIF image file comments, the possibility of file separation andconsequent mishandling or mis-matching of the separate components of thePAC application is virtually eliminated. Alternatively, the TIFFstandard format advantageously can also be used to co-join field anddigital image data.

It will also be appreciated that the concept of embedding comments intothe GIF or TIFF image file format is a standard practice employed bythose of ordinary skill in the art of graphic image preparation, e.g.,by photographers and digital artists who wish to identify their works.However, it should also be noted that the use of a comment block storingdata fields used in reconstructing a completed form, e.g., a completedPAC form, has never before been described or suggested. Furthermore,since the technique described above is a novel solution toelectronically forwarding an insurance claim form and an associatedattachment as one, the use of the comment block to store the PAC formfield data is likewise a unique and novel aspect according to thepresent invention.

In yet another alternative exemplary case, the digitized x-ray isautomatically added (inserted) to the electronic form by the serviceprovider's AIC software and forms a single computer file, as depicted inFIG. 5B. It should be noted that the non-text portion of the PACapplication is labeled with the same provider Document IdentificationNumber (DIN) as used on the text portion, i.e., the electronic PAC form.These two objects together now form the patient record, i.e., thepatient's PAC application. The PAC application is now ready to be sentto the insurance company.

During step S106, the service provider's office staff then transmits thecompleted PAC application to the insurance company. For example, whenthe transmission icon of the GUI AIC software running on the serviceprovider's computer system 210 is activated (e.g., "clicked" on), thefollowing subsets are automatically executed:

(a) A check is first performed to ensure that the PAC application hasbeen completely filled out. In the event that problems and/or errors arenoted by the AIC software, the system user is notified of the error byan appropriate annunciator, e.g., the suspect area can be highlightedand a message concerning the problem and/or error could be generated anddisplayed on the monitor;

(b) A hard copy of the PAC application is printed out, if desired, bythe service provider. The hard copy may advantageously be placed in thepatient's permanent file;

(c) Moreover, and more importantly, the completed PAC application isarchived in the service provider's computer system 210, 240. It will beappreciated that this archive copy can be accessed in several ways suchas by patient name, social security number, document identificationnumber, etc. That is, it can be accessed using any of the informationthat has been entered into the PAC form; and

(d) The service provider's computer system establishes a connection withthe on-line service 400 and transmits the patient's PAC application tothe insurance companies e-mail address. See task T1a of FIG. 3. It willbe appreciated that the e-mail addresses of all the insurance companieshave been stored in the AIC software residing in the memory of computersystem 210. Advantageously, the PAC application can be transmittedimmediately or can be scheduled for transmission at a convenient time,i.e., can be transmitted after all of the PAC applications and otherforms have been prepared for the day. Preferably, the AIC software onthe service provider's computer system 210 keeps a record of when thePAC application was sent. In addition, the AIC software maintains anduses the proper protocols so that when the is PAC application reachesthe intended insurance company, it arrives there with the alpha-numericportion of computer file intact, i.e., the information is stored infields that can be read by the corresponding AIC software module in thecomputer system 310 at the insurance company.

It should be noted that the specific transmission path taken by the PACapplication from the service provider's computer system 210 to thecomputer system 310 maintained by the insurance company is not anessential limitation of the novel system and corresponding operatingmethod according to a preferred embodiment of the present invention. Theonly requirement of a transmission path is that it maintain the digitalintegrity of the PAC application computer file. Thus, the patient's PACapplication can be sent to the insurance company in several ways usingmodems 216 and 316, including via normal phone service, an on-lineservice, or bulk data transmission lines.

In an alternative exemplary case, the completed PAC applications mayeven be transferred to tape or CD-ROM and then sent through the U.S.Postal Service 100 of FIG. 1 to the insurance company's mailroom 320.For purposes of the discussion which follows, only the exemplary case inwhich the PAC application is transmitted via the on-line service 400 isdescribed in any detail.

One of the beneficial aspects of the present invention is provided bythe combination of the customizable claim form on the service provider'scomputer 210 and the use of any non-restrictive communications channel,i.e., the insurance companies are able to freely modify informationrequirements demanded of the service providers. Existing electronicclaims processing systems, such as NEIC, are based on a clearinghouseconcept, as illustrated in FIG. 6A. In a clearing house system, allclaims enter the clearinghouse computer(s), are manipulated, and thenare transmitted to the appropriate insurance company. One consequence ofthe clearinghouse architecture is that it puts a constraint on theinsurance company to use a standardized claim form. The individualinsurance companies have little or no control of the information contentin the form. Moreover, because the claim form is standardized, changesare very difficult to make, i.e., any change requires that all memberinsurance companies make is the change together.

In contrast, placing AIC software packages in the providers' offices andin the insurance company processing centers, where the packages arecoordinated with one another, allows every provider to transmit claimform updates to every payer. There is no central computer thatmanipulates the claim forms. In the provider's office, the change wouldbe reflected primarily in changes to the number of fields needinginformation and, rarely, in the addition of a new field to be completedby the provider.

As illustrated in FIG. 6B, the interchange between the provider's officeand the insurance company(ies) advantageously can be performed using anonline service or Internet Service Provider (ISP), providing that theservice provider permits 8-bit file interchanges. In that case, theupdate information could be transmitted to the provider when theprovider dials into the online service. Thus, while it is true thattransmission accomplished using e-mail involves an intermediarycomputer, the online service merely provides a mail box and places noconditions on the insurance information contained in the claim itself.

Advantageously, the non-clearinghouse architecture and coordinated AICsoftware package facilitates the provision of the customizable claimform. That is, each insurance company can determine the content of itsown claim form. The packages used by the providers are instructedregarding the information content, protocols, etc. each insurancecompany wants its claim to have. It will be appreciated that the packageat each insurance company is designed to accept only those claims thatmeet the specifications of the respective insurance company. Inaddition, if an insurance company wants to change the content of itsclaim form, it can do so independently of the other insurance companies.

Beneficially, the non-clearinghouse architecture reduces costs, allowsfor the direct digital interchange of data from one insurance company toanother, and permits many different types of forms to be run off thesame system, e.g. commercial insurance claims and workers' compensationclaims can both be processed in the provider's office using the samecustomizable claim form. This produces a claims processing system whichis more robust than anything on the market today.

During step S107, the PAC application is pre-processed by thevalue-added service provider 500. For example, the patient's PACapplication can be accessed by the employees of the value-added servicecompany to perform services for either the patient, the serviceprovider, or the insurance company, or any combination thereof. See taskT2 of FIG. 3. These value-added services could include archiving of thepatient's dental x-rays so that all records for a particular patient arecentrally stored, screening of the entire PAC application for errors,compiling statistics on all PAC applications and, in some instances,even performing the review process for the insurance company.

Next, the insurance company accesses the PAC applications at the on-lineservice during step S108. In an exemplary case, each insurance companyhas an E-mail address specifically for the purpose of receiving PACapplications. An insurance company accesses its E-mail box and finds awaiting list of PAC applications which are subsequently downloaded toGUI-capable computer system 310. In a preferred embodiment as shown inFIG. 3, the GUI-capable computer system 310 advantageously is connectedto the claims management mainframe computer 350 of the insurance company300. Preferably, the GUI-capable buffer computer system 310 is apersonal computer (PC) or a PC server which advantageously can beoperated in parallel with but separate from the insurance company'smainframe computer 350; data, however, beneficially can be interchangedbetween the buffer computer system 310 and the mainframe computer 350.In an exemplary case, as the personnel at the insurance company 300apply an insurance company document identification number (DIN) to eachreceived PAC Application, the field data contained therein is copied bythe buffer computer system 310 and transmitted to the mainframe computer350. See task Tb of FIG. 3.

Alternatively, the entire PAC application advantageously could be copiedby the buffer computer system 310 and downloaded to the mainframecomputer 350, where the image portion of the PAC application then canremoved from the mainframe's memory. This approach employs basically thesame distribution of information, i.e., text form in the mainframe 350and field data and images in the buffer computer system 310.

In an exemplary case, this buffer computer 310 is part of a local areanetwork (LAN) 313, which is connected by high bandwidth cables topersonal computers or other GUI-capable terminals 311, 312 at the desksof the individual reviewing dentists and claims adjusters, respectively.It should be noted that the necessary AIC software has been loaded ontothe server 310, the individual personal computers 311, 312, and themainframe 350. Preferably, once the patient's PAC application has beenreceived, the system's AIC software at either the value-added serviceprovider 500 or the insurance company's computer 310 automaticallynotifies the referring service provider that the PAC application hasbeen received for processing, e.g., using a conventional E-mail message.

At step S109, the reviewing dentist calls up the graphics portion of thePAC application, in an exemplary case, from the server 310 to a personalcomputer 311, each of which is running the appropriate AIC software, viathe LAN 313 using the assigned DIN. See task T4 in FIG. 3. The reviewingdentist then calls up the text portion of the PAC application from themainframe computer 350 using the terminal 351. It will be appreciatedthat the sequence can be reversed at the reviewing dentist's option. Itshould be noted that some small insurance companies may not even requireserver-LAN 310, 313 system discussed above, but just a single PC thatwill incorporate the functions of the elements 310, 311, 312, and 313.In any event, the reviewing dentist calls up a patient's PAC applicationusing both his personal computer 311 and terminal 351. When thishappens, the system AIC software automatically generates the insurancecompany's Predetermination Form on one of the two screens 311, 351. Theinstalled AIC software advantageously can automatically transferwhatever information from the PAC application to the Predeterminationform that is useful in completing the Predetermination form, e.g.,repetitive information/fields. For instance, the service provider'sDocument Identification Number (PDIN) and the Provider IdentificationNumber (PIN) can be transferred automatically to the Predeterminationform. In addition, the AIC software can be written to display theinformation in the PAC form on the screen 351 in exactly the way thatthis particular insurance company wants it displayed.

In a alternative implementation, a single monitor on the computer 311supporting multiple windows, at least one of which runs terminalemulation software for displaying the output of the mainframe computer350, could advantageously be used to display both parts of the PACapplication.

With the AIC system described above, the use of "fields," thecustomizable claim form, and the placing of coordinated AIC software atboth the service provider's office and the insurance company, haseliminated the need for standardized forms. The result is that eachinsurance company gets exactly the information it wants and has itdisplayed in exactly the way it wants. Thus, the compromise of astandardized claim form as is required with the present NEIC system isavoided.

In an exemplary case, the reviewing dentist is provided with threemonitors or a large graphics-capable monitor having a multi-page displaymode, on which can be displayed the three pages of the patient file. Itwill be appreciated that this configuration is optimized to facilitaterapid review of the PAC application. The reviewing dentist enters anInsurance Company Document Identification Number (DIN) at this point,which number is affixed to all three pages of the patient's file.

During step S110, the reviewing dentist reviews the PAC application.More specifically, the review process consists of a review of themedical facts or evidence (i.e., the text and x-ray information in thePAC application), as well as a review of the patient's insurance policy.Once the reviewing dentist has made his analysis, he goes to thePredetermination form, i.e., the third page, and enters the requiredinformation to either approve or disapprove the procedure during stepS111. The specific details regarding the information provided by thereviewing dentist will depend on the procedures established at eachindividual insurance company. Either the reviewing dentist or anotherperson, e.g., a claims adjuster, will do the review of the patient'sinsurance policy.

Advantageously, there are several ways to gain access to thisinformation. First, the server 310 can have information on every policyholder loaded into its memory. Second, the benefits reviewer, i.e.,either the reviewing dentist or the claims adjuster, can have anothermonitor 351, 352 on his desk that is connected to the company mainframecomputer 350. Thus, all that the benefits reviewer must do is select thepatient's insurance ID number and his benefits sheet will appear. Thebenefits reviewer then reads off the information that must be entered inthe Predetermination form and enters the information into the either theGUI-capable computer system 310/311/312 of the mainframe computer 350during step S111. It should again be noted that there is an electronicconnection, in the preferred embodiment, between the mainframe computer350 and the server 310. Whatever information is deemed necessary by thatparticular insurance company to complete the Predetermination form canbe transferred between the mainframe computer 350 and the buffercomputer system 310 by entering data on one of the terminals 311, 351.See, for example, task T5 in FIG. 3.

At this point, the Predetermination form is ready to be sent to thereferring service provider. When the transmit icon on the computerscreen of the benefit reviewer's GUI-capable computer system 311, forexample, is activated (e.g., by being "clicked" on), the followingsubsteps are automatically performed:

(a) First, a check is performed to verify that the Predetermination formhas been completely and properly filled out. If errors are detected, theAIC software notifies the operator via an appropriate annunciator;

(b) The Predetermination form and the patient's PAC application aredownloaded to the buffer computer 310. See task T5a. From this platform,the company accesses the on-line service 400 and transmits thePredetermination form, i.e., just the information "fields", to theservice provider's e-mail address, which is stored in the memory ofserver 310. See task T6. In the AIC software, records are kept as towhich PAC applications have been sent and when and to whom. The properprotocols are used so that when the application reaches the serviceprovider, it arrives there as a computer readable file, i.e., theinformation is stored in "fields" that can be read by the AIC softwareat both the insurance company and the service provider's office;

(c) A hard copy of the Predetermination form and x-ray are printed, ifdesired, by the insurance company, see task T7;

(d) The complete patient file is archived in the insurance company'scomputer system 310, 340, if desired. See task T8. Otherwise, just theelectronic Predetermination form and the PAC application are saved; and

(e) The entire three page patient file is now cleared from the reviewingdentist's displays 311, 351 and the AIC software prompts the reviewingdentist as to whether another patient file should be accessed.

During step S112, the service provider accesses his e-mail address withthe on-line service 400. All Predetermination forms which have beenreceived are automatically delivered to the service provider's computersystem 210 for insertion into the appropriate patient file. The serviceprovider then reviews the Predetermination forms. Upon evaluating thedecision of the reviewing dentist, the service provider can eitherperform the procedure (if approved) or discuss the matter with thepatient's insurance company (if not approved).

During step S113, the approved procedure is performed by the serviceprovider. Once the approved procedure has been completed, the serviceprovider preferably sends in the Final Payment Claim (FPC) form. In anexemplary case, this could be as simple as just filling out anothersection of the Predetermination form and signing it using the electronicsignature pen, as discussed above. It should be noted that in FIG. 3,this is labeled as P*. Alternatively, if the insurance company sodesires, a separate form just for this purpose can be employed. Thislatter form, which advantageously is the same customizable claim formdiscussed above, is stored in the memory of the provider's computer,must have the Insurance Company's DIN for this particular patient'sprocedure and all other needed information transferred to it, whichadvantageously can all be done by the AIC system software at step S114.At step S115, the Final Payment Claim form is transmitted back to theinsurance company. See task T9 of FIG. 3. In an exemplary case,activating the transmit icon on the service provider's computer system210, e.g., by "clicking" on it, automatically results in the executionof the following substeps:

(a) A check is performed to see that the form has been completely andcorrectly filled out. If an error has occurred, the AIC software alertsthe operator of the detected error;

(b) A hard copy of the form is printed out, if desired, by the serviceprovider;

(c) The complete patient's electronic file is archived in the serviceprovider's computer system 210, 240. It will be noted again that thepatient's electronic file can be accessed by patient name, socialsecurity number, document identification number, etc.; and

(d) The computer system 210 establishes a connection with the on-lineservice and transmits the patient's Final Payment Claim (FPC) form tothe insurance company's e-mail address.

As previously discussed, the AIC software on the service provider'scomputer system 210 advantageously may include facilities fortransmitting the Final Payment Claim form to the insurance company at alater time, e.g., for transmitting all of the days PAC application andFPC forms at one time.

It will also be noted, as discussed above, that the AIC softwaremaintains records as to which claim form was sent and when it was sentto the insurance company. In an exemplary case, the E-mail address towhich the Final Payment Claim form is sent is different from the addressused in transmitting the PAC application. Since the Final Payment Claimform does not include a digitized image, i.e., a digitized x-ray, theinsurance company may choose to have the Final Payment Claim formdirected to an E-mail address accessible from the mainframe computer350. If the insurance company's processing protocol requires anindependent review of the PAC application, the Predetermination form andthe Final Payment Claim form before payment can be authorized, theE-mail address advantageously can be accessed from either the server 310or the mainframe computer 350, since these two computer systems areelectrically coupled at the insurance company 300.

The insurance company then receives the Final Payment Claim forms duringstep S116 when it accesses its Final Payment Claim forms mail box. In anexemplary case, the computer system receiving the Final Payment Claimforms is not the claims management mainframe computer 350 of theinsurance company but, rather, it is a personal computer or server 310that is part of a parallel system having an electronic connection to themainframe computer 350. This buffer computer 310 advantageously can bepart of a LAN 313. The buffer computer 310 is connected by highbandwidth cables to the personal computers or GUI-capable terminals 312located at the claims adjusters's desks. See task T10. It should againbe noted that the appropriate AIC software modules have been loaded ontoboth the server 310, the personal computers 312 and the mainframecomputer 350. It will be appreciated that the information entered incomputer 312 advantageously can be automatically transferred to themainframe 350 through the transmission path including the computer 312,the buffer computer 310 and the electronic connection to the mainframecomputer 350.

The Final Payment Claim form is then reviewed during step S117. Theadjuster reviewing the Final Payment Claim form can, if necessary, callup the PAC application from the memory of the server 310, since theoriginal Insurance Company Document Identification Number for thecorresponding PAC application was transferred to the Predeterminationform and, thus, to the Final Payment Claim form. In addition, theadjuster can, if need be, call up the information on the insurancepolicy of the particular patient stored in mainframe computer 350 viaterminal 352. Preferably, the insurance company provides the adjusterwith a separate monitor 352 connected to the claims management mainframecomputer 350.

Whatever internal paperwork is necessary to be filled out isautomatically downloaded with the Final Payment Claim form itself by theappropriate AIC software module. Part of this paperwork will preferablybe form(s) which must be completed so as to order a check issued to theservice provider along with an Explanation of Benefits (EOB). Also atstep S118, whatever information is necessary to be entered into themainframe 350 can be entered directly through the use of the terminal352 or indirectly through computer 312, the buffer computer 310 and theelectronic connection to the mainframe computer 350.

Finally, upon activating the transmit icon on the insurance company'spersonal computer 312, for example, the following substeps areautomatically executed:

(a) A check is again preformed to see that the form has been completelyand correctly completed and the operator is notified if an error hasoccurred;

(b) A hard copy of the form is printed out, if desired by the insurancecompany;

(c) The complete patient file is archived in the insurance company'scomputer system, e.g., on the server. It should again be noted that thepatient file can be accessed using the patient's name, social securitynumber, or an assigned document identification number, etc.; and

(d) A payment draft is issued, in the approved amount, to the serviceprovider. This can be done through any number of methods, includingprinting a hard copy check and forwarding it through the U.S. postalservice, electronic funds transfer, etc. Each form of payment will beaccompanied with the normal description of the service to which thesefunds should be applied, i.e., the EOB (Explanation of Benefits).

The preferred embodiment was described as transmitting digitized dentalx-rays as part of an integrated PAC application file transmitted betweena service provider and an insurance company. However, the presentinvention is broadly directed to the integrated transmission of any"electronic text form" and any "attachment." Further, the presentinvention is not limited to transmissions between providers andinsurance companies. Rather, it is intended to facilitate thetransmission of electronic forms with attachments between any person ororganization and any other person or organization.

For example, the present invention has utility in such other areas asProperty/Casualty Insurance and law enforcement. Thus, the "attachment"need not be an x-ray or other type of image. Rather it can be anyinformation which is not easily incorporated into an associated"electronic text form" and/or cannot be easily displayed on an existinglegacy computer system. Attachments can include, but are not limited to,pictures, graphs, sound recordings, and nonstandard text. Examples wouldbe x-rays, CTs, MRIs, EKG or EEG recordings, i.e., strip charts,digitized video signals such as Moving Picture Experts Group (MPEG)compressed video signals, transcriptions of Operating Room Notes,estimates for repairs to a house or car, EOBs (Explanation of Benefits),additional ASCII text, and the like. As used in this description, allparticulars regarding a specific "attachment," such as medicalspecialty, acquiring modality, the patient's problem, etc., can beignored. These are details having absolutely no bearing on the essenceof the present invention. The only requirements are that the informationmust be something that can be digitized and therefore put into the formof a computer file, and that once in this form, it can be "read,reviewed or interpreted" by the person or organization receiving it.

The exemplary preferred embodiment discussed above addresses only astand-alone system of computers, which is independent of the practicemanagement software in the local dentist's office, the claims managementsoftware at each insurance company, and of clearinghouses such as NEIC.However, it will be appreciated that there is an entire spectrum ofdifferent ways to structure a system which will support "attachmentintegrated claims" which will be readily apparent to a person ofordinary skill in the art (after having the benefit of the presentdisclosure), all of which are encompassed by the present invention.

It should also be noted that the AIC software described thus far hasbeen independent of the service provider's practice management software.However, one alternative preferred embodiment calls for integrating theAIC software with the practice management software. This would furtherreduce the amount of time spent actually filling out the PAC applicationand the other paperwork involved in the overall claims process.

Electronic filing of standard 100% text claims is now being supported bymany practice management systems and by stand-alone electronic claimssoftware systems. In another alternative preferred embodiment, the AICsoftware could be incorporated into these systems as a means of sendingthe x-ray part of the PAC application.

It should also be mentioned that the present invention represents atotal solution on three levels to the problem of streamlining theprocessing of insurance claim forms with attachments. First, the systemfrom provider to third party payer is totally digital. The presentinvention includes an integrated system of hardware and AIC softwarethat allows: (1) providers to create an electronic (digital) version ofa patient's PAC application (text and x-ray); (2) providers to transmitthe PAC application to an insurance company; and (3) the insurancecompany to read the patient's PAC application. Thus, it creates acoherent system for the filing, transmission and processing of "claimswith attachments."

Secondly, the present invention is an industry-wide system which allowsevery provider to interface with every third party payer. Finally, thepresent invention is a system which permits all communications betweenthe service provider and the insurance company to be totally electronic.The present invention makes the entire process electronic from theinitial preparation of the PAC form to the payment of the final claim.Communication is digital in both directions.

As discussed above, the patient, the service provider, the insurancecompany, or any combination thereof may prefer that all communication beperformed through a value-added service provider 500. The servicesperformed by the value-added service provider 500 advantageously couldinclude any or all of the services listed immediately below.

First, the value-added service provider 500 may act as a National DentalData Bank (NDDB), i.e., a data bank storing patient dental images.Limited information regarding the patient from the PAC form is attachedto the digital x-ray to produce a digitized x-ray record. Thisinformation could include, for example, the date that the x-ray wastaken, the identity of the service provider who took the x-ray, thepatient's name and social security number, etc. The digitized x-rayrecord is archived at NDDB for the patient. This would allow theretrieval of the x-ray by the patient at any time for any reason, e.g.,the patient could ask that the x-ray and claim be sent to anotherdentist for a second opinion and/or for a second price estimate. Infact, the patient may request that the PAC application be sent to otherqualified service providers so that they could competitively bid on theneeded procedure.

In addition to the NDDB function, the value-added service provider 500could perform prescreening of the PAC applications for errors and couldprovide statistics to both the service providers and the insurancecompanies regarding, for example, the frequency at which a procedure isperformed or the frequency at which follow up treatment is requiredafter a first procedure is performed. The value-added service provider500 could also do the prior approval review for an insurance company orcould provide other services tailored to suit the needs of the serviceprovider, the patient, and/or the individual insurance company.

It should be mentioned that there are three outside areas of softwarethat advantageously can be taken into consideration, or ignored, withthe present invention. These are practice management software run by theservice provider, claims management software run by the insurancecompany, and clearinghouse software. The present invention allows forthe entire spectrum of interfacing, from a totally stand-alone systemfor electronic claims processing to one that is fully integrated withpractice management software, claims management software, and the NEIC.Moreover, the present invention is specifically contrived so that it canbe used simultaneously in all modes. That is, one insurance companycould choose to have no interfacing between the computer 310 running theAIC software and its mainframe computer 350, while, at the same time,another insurance company could choose to have AIC software runningsimultaneously on both the mainframe computer 350 and the buffercomputer system 310. Thus, each operating mode or methodology could beconsidered to be a different preferred embodiment of the presentinvention, notwithstanding the fact that all modes are expected to beoperating simultaneously.

The present invention was motivated by a desire to solve a problem whichhas existed for many years. The AIC software was designed with this inmind. Thus, for example, redundant information is automatically movedfrom one form and file to another along the chain of operating steps,i.e., from one document to another within a given insurance company'sset of forms. Moreover, the AIC software advantageously can be writtenC++ or some other appropriate programming language. The reason for thisso that when information in entered into areas of the electronic PACforms, it is entered as a "field." Being a "field" it can be used as alogic control device, as discussed in greater detail above.

The overall workflow problem to be addressed is treated as a coherentwhole. Thus, AIC software is specifically designed so that, at each stepof the preferred operating method, the fact that the information is indigital form is used to streamline the process. Thus, the AIC softwareis designed to eliminate inefficiencies and deficiencies that exist incurrent claims handling systems. For example, the information itself canbe used as a logical control device and it can also be transferred fromone document to another. It should be noted that all available forms arewritten into the AIC software so that they are coordinated with oneanother, that is, they know where each has a similar "field."

It should also be noted that the AIC software automates much of theoverall insurance claims processing, thus eliminating many of the areasthat are repetitive or prone to human error. These areas include thefollowing:

(a) Filling in the service provider's information. Although eachinsurance company may require something different in the way of serviceprovider information, the AIC software can store consolidated serviceprovider information so that the information need be entered only once.For example, the service provider need only enter his telephone numberonce; the AIC software can reformat this basic information specificallyfor each individual insurance company's form;

(b) Transmitting the PAC application to the correct e-mail address, thuseliminating the errors associated with hand addressing and stamping themailing envelope;

(c) Checking each completed form, i.e., PAC application andPredetermination form, for accuracy and completeness, while it is stillat the provider's office or the insurance company; and

(d) Simultaneously transmitting, archiving, and printing the completedforms, e.g., the PAC application.

It will be appreciated that many such advantages will be evident tothose of ordinary skill in the art from having the requisite PAC formstored in the AIC software on the service provider's computer system210, 240.

Moreover, the AIC system advantageously can be optimized to limitunnecessary information. For example, the system can make use ofscanners 220 which have portions of their scanning area physically orelectronically masked out, which reduces both scanning time andtransmission time by minimizing the size of the digitized x-rayproduced, for example, during step S104. The provisions for the use ofdigital and digitized signatures also eliminates unneeded papershuffling.

It should again be noted that the major improvement in efficiencyattributable to the AIC system results from combining or coordinating anelectronic PAC form with an electronic (digitized) x-ray. Thiselectronic x-ray will have a document identification number assigned toit.

In addition, the AIC system and corresponding method according topreferred embodiments of the present invention provide severalconvenience features which are only possible when using a fullyelectronic filing system. For example, the AIC system facilitatesautomatic acknowledgment by the insurance company that it has receivedthe PAC application. Moreover, the AIC system provides automatictransfer of pertinent information from the PAC application to thePredetermination form. Furthermore, the AIC system components at theinsurance company preferably allow simultaneous viewing of the threedocuments needed to complete the Predetermination form. In addition, theAIC system and requisite software automates the entire transmitting andarchiving processes of the PAC application and the Predetermination format the insurance company.

In some instances, the electronic reuse of the Predetermination form asthe Final Payment Claim form means that the service provider need onlyindicate the date that the procedure was performed and enter the serviceprovider's facsimile or electronic signature. The AIC software module atthe provider's office requests these be entered into P, i.e., thePredetermination form, to create P*, i.e., the Final Payment Claim form,and then transmits P* to the final claims e-mail address for payment.Moreover, the only information that needs to be sent from the serviceprovider to the insurance company is the insurance company's assigneddocument identification number, the date of completion and the serviceprovider's signature.

The preferred embodiments of the AIC system according to the presentinvention provide dentists in the field with the necessary hardware andsoftware which allows them to create an electronic (digital) version ofa patient's PAC application, both the text and the required patientx-ray. The AIC software automatically adds these two data types togetherto form a single entity, the patient's PAC application. Moreover, theAIC system provides the insurance companies with hardware and softwarewhich allows them to read the patient's electronic PAC application. Foreach insurance company, this application is tailored so that it containsthe specific information required by that company and it contains thatinformation in the form required by that company. As such, the necessityto force standard formats on the insurance industry is eliminated.Moreover, the AIC system and software automatically attaches a partiallyfilled out Predetermination form to the patient's PAC application whenit is called up for review and approval. Moreover, the AIC system andsoftware completely eliminates the time consuming process of actuallyhandling the patient's film x-ray by insurance company personnel.

Other modifications to and variations of the invention will be apparentto those skilled in the art from the foregoing disclosure and teachings.Thus, while only certain embodiments of the invention have beenspecifically described herein, it will be apparent that numerousmodifications may be made thereto without departing from the spirit andscope of the invention, as defined in the appended claims.

What is claimed is:
 1. A combination comprising:a first storage mediumstoring computer readable instructions for permitting a first computersystem to receive textual data as field data, to assemble said fielddata and a corresponding digitized attachment into a first file and totransmit the first file to a second computer system via a communicationschannel; a second storage medium storing computer readable instructionsfor permitting the second computer system to receive said first file viathe communications channel, to display the corresponding digitizedattachment on a second screen of the second computer system, and totransfer said field data to a third computer operatively connected tothe second computer; and a third storage medium storing computerreadable instructions for permitting the third computer system toreceive said field data from said second computer, to display said fielddata on a third screen of the third computer system and to generate asecond file including portions of said field data extracted from saidfirst file.
 2. The combination as recited in claim 1, wherein saidsecond computer is a buffer computer system and wherein third computeris a mainframe computer.
 3. The combination as recited in claim 1,wherein said first, said second and said third storage media comprisefirst, second and third hard disks, respectively.
 4. The combination asrecited in claim 1, wherein said digitized attachment is a digitizeddental x-ray.
 5. The combination as recited in claim 1, wherein saidinstructions in said second and said third storage media permit saidfield data, said digitized attachment and said second file to besimultaneously displayed.
 6. A combination comprising:a first storagemedium storing computer readable instructions for permitting a firstcomputer system to receive textual data as field data, to assemble saidfield data and a corresponding digitized attachment into a first fileand to transmit the first file to a second computer system via acommunications channel; a second storage medium storing computerreadable instructions for permitting the second computer system toreceive said first file via the communications channel, to display thecorresponding digitized attachment on a second screen of the secondcomputer system, and to transfer said field data to a third computeroperatively connected to the second computer; and a third storage mediumstoring computer readable instructions for permitting the third computersystem to receive said field data from said second computer, to displaysaid field data on a third screen of the third computer system and togenerate a second file including portions of said field data extractedfrom said first file, wherein:said first file follows a predeterminedgraphic image interchange file format; and said field data isincorporated into comment blocks associated with said predeterminedgraphic image interchange file format.
 7. The combination as recited inclaim 6, wherein said second computer is a buffer computer system andwherein third computer is a mainframe computer.
 8. The combination asrecited in claim 6, wherein said first, said second and said thirdstorage media comprise first, second and third hard disks, respectively.9. The combination as recited in claim 6, wherein said digitizedattachment is a digitized dental x-ray in said predetermined graphicimage interchange file format.
 10. The combination as recited in claim1, wherein said instructions in said second and said third storage mediapermit said field data, said digitized attachment and said second fileto be simultaneously displayed.
 11. A method for operating a computersystem including first, second and third computers, each of said first,second and third computers including a memory, an input device, and adisplay, respectively, said first and said second computers beingconnected to one another by modems and a common communication line, andsaid first computer including a digitizing device, said methodcomprising the steps of:(a) retrieving a first form from storage in thefirst computer's memory and displaying said first form on the firstcomputer's display; (b) writing first field data to said first formusing the first computer's input device; (c) digitizing a patient'sx-ray to thereby generate a digitized x-ray; (d) combining saiddigitized x-ray and said first form so as to generate an attachmentintegrated file by inserting said first field data into a comment blockwithin said digitized x-ray so as to generate an attachment integratedfile; (e) transmitting said attachment integrated file to the secondcomputer; (f) transmitting said first field data from said secondcomputer to said third computer; (g) generating a second form uponreceipt of said attachment integrated file, said first and second formscontaining at least a portion of said first field data; (h) displayingsaid first form, said second form and an image corresponding to saiddigitized x-ray on respective displays of said third computer and saidsecond computer; (i) writing second field data to said second form usingsaid third computer's input device; (j) transmitting said first andsecond field data corresponding to second form back to the firstcomputer.
 12. The method as recited in claim 11, further comprising thesteps of:(k) receiving said first and second field data corresponding tosaid second form on the first computer; (l) reconstructing anddisplaying said second form on the first computer's display; (m) addingcompletion data to said second form using the first computer's inputdevice to thereby convent said second form into a third form; and (n)transmitting said first and second field data and said completion datacorresponding to said third form from the first computer to a selectedone of said second and third computers.
 13. The method as recited inclaim 11, further comprising the steps of:(o) receiving said first andsecond field data corresponding to said second form on the firstcomputer; (p) generating a third form responsive to receipt of saidfirst and second field data corresponding to said second form; (q)automatically transferring selected portions of said first and secondfiled data to said third form; (r) entering completion data into saidthird form using the first computer's input device; and (s) transmittingsaid selected portions of said first and second field data and saidcompletion data corresponding to said third form from the first computerto a selected one of said second and third computers.
 14. The method asrecited in claim 11, wherein said step (e) comprises the steps of:(e)(i)transmitting said attachment integrated claim application to an on-lineservice; and (e)(ii) transmitting said attachment integrated claimapplication from said on-line service to the second computer.
 15. Themethod as recited in claim 11, wherein said step (i) comprises the stepsof:(j)(i) transmitting said second form to an on-line service; and(j)(ii) transmitting said second form from said on-line service to thefirst computer.
 16. The method as recited in claim 11, wherein:saidattachment integrated claim application is a Prior Approval Claimapplication; said digitized x-ray comprises one field of said attachmentintegrated claim application; and said second form is a Predeterminationform.